LTSS Authorization Coordinator

Fallon Health•Worcester, MA

About The Position

The FH LTSS authorization process is an essential function to FH’s compliance with CMS regulations, NCQA standards, other applicable regulatory requirements, and customer expectations. The LTSS Authorization Coordinator serves to administer the FH prior authorization process as outlined in the Plan Member Handbook/Evidence of Coverage, Medical Necessity Guidelines, departmental policies and procedures, and regulatory standards. The LTSS Authorization Coordinator serves as a liaison between FH members and/or provider offices and FH with their authorization management issues. Thorough research, documentation, and corrective action planning must be established for each respective case and adjudication completed in accordance with existing regulations, policies, and standards.

Requirements

High School Diploma; College degree (B.S. or B.A.) or equivalent preferred
1-3 years professional experience in related position, preferably in health care.
Experience in a managed care, call center setting or physician’s office; knowledge of managed care and/or utilization management strategies preferred.
Excellent writing skills with familiarity and comfort with medical terminology.
Ability to work independently and make appropriate decisions within the realm of set business and benefit guidelines.
Excellent interpersonal communication and critical thinking skills.
Excellent research and documentation skills.
Excellent writing skills.
Computer literate, particularly in Windows based applications (Word, Excel, PowerPoint, and Access).
Experience in EMR or other healthcare documentation systems preferred

Nice To Haves

Medical Terminology or Medical Coding helpful

Responsibilities

Administers FH LTSS authorization processes as outlined in Member Handbook/Evidence of Coverage for NaviCare and in compliance with applicable CMS and NCQA standards and other state or federal regulatory requirements. Strictly adheres to department turn-around time standards established in accordance with regulatory standards.
Enters, researches, investigates, and documents all authorizations from receipt to notification into QNXT and/or TruCare for NaviCare and other product lines as needed.
Authorization management for NaviCare members, including but not limited to LTSS services- LTSS services are defined as the services used by individuals of all ages with functional limitations and chronic illnesses who need assistance to perform routine daily activities such as bathing, dressing, preparing meals, and administering medications.
First point of contact to answer all inquiries sent to the Care Management authorization email, Including but not limited to, researching and corresponding regarding any type of authorization related questions and or issues, assisting DME vendors with invoice processing, working with Fallon Health UM to process LTSS service requests, resolving any provider related authorization issue and concern/questions and assisting Fallon Health claims unit when needed
Manages and works the Care Management Right Fax Authorization folder and in an organized manner each business day.
Manages and works the long-term care and short- term custodial tasks; ensuring authorizations get sent to the facilities promptly.
Responsible for ensuring LTC and STC authorizations are coded according to member’s appropriate rating category and for the timeframe outlined in the policy and procedure related to LTC authorizations.
Collaborates closely with the LTC team to ensure consistency of authorizations in alignment with member needs and facility documented rating category accuracy.
Applies criteria to ensure LTSS services requested meet criteria; and accurately enters authorizations into Fallon Health systems into a timely manner to ensure compliance with CMS timeframes for all appropriate Fallon Health products.
Reviews and evaluates incoming requests for completeness and accuracy and discusses any discrepancies with the care team; teaching staff when issues are identified; and working with Care Management Leaders reporting when staff need further teaching to improve submissions.
When processing LTSS authorization requests; screens for member eligibility and follows process when members are not eligible.
Data enters LTSS authorization requests and sends them to LTSS RN Reviewer to complete review against Medical Necessity criteria, state, and federal guidelines.
Supports with sending notification of authorization changes to the appropriate vendor/provider contacts when changes to authorizations are finalized in TruCare.
Educates care management staff, vendors, and providers on authorization processes.
Proactively investigates pending claim issues associated with authorizations and works to identify a solution and implements correction to resolve claim issues.
Sends notification to appropriate vendor/provider contacts in cases of decreased service level or member not meeting eligibility guidelines for service Notifies members and providers of any additional instructions necessary once authorization approval has been obtained from the reviewers; answers question and provides direction and support.
Adheres to department standards for completion of authorization turn-around time and notification.
Answers authorization questions from members and providers, as needed.
Communicates both by telephone and on-site, as needed, with FH providers and staff to facilitate the Pre-Authorization Process.
Supports claims functions through authorization adjustment guidelines to assist with adjudication of claims provided for missing information.